Transitional Care is an innovative topic in the healthcare arena. According to the Agency for Healthcare Research and Quality (AHRQ) more than one-third of Medicare beneficiaries who are discharged from a hospital are re-hospitalized within 90 days and most of these are preventable. This indicates a need to improve coordination of post-discharge care. Health Care Reform’s Patient Protection and Affordable Care Act Section 3026:

Directs the Secretary to establish a Community-Based Care Transitions Program which provides funding to eligible entities that furnish improved care transitions services to high-risk Medicare beneficiaries. Nurses are uniquely skilled and positioned to lead this initiative. Assessing needs; providing care; managing/directing care; communicating with interdisciplinary care teams; and educating patients, caregivers and other healthcare providers are competencies required to deliver Transitional Care in an effective and efficient manner. Additionally the nursing profession is adept at monitoring and analyzing outcomes of care.

In an effort to prepare nursing leaders to meet this challenge, knowledge of the scope of the issue and the success or limitations of existing models is key.